Over the last century, traditional Chinese medicine has co-existed with allopathic medicine (217). (See the Introduction for a description of traditional Chinese medicine.)
There are 350 000 staff working at more than 2500 hospitals of traditional medicine in China. In addition, 95% of general hospitals have units for traditional medicine and 50% of rural doctors are able to provide both traditional and allopathic medicine (213). In 1949, there were 276 000 practitioners of traditional medicine in China. The figure increased to 393 000 in 1965 and 525 000 in 1995. Among these traditional medicine practitioners are 257 000 traditional medical doctors who graduated from traditional medical universities with a knowledge of both traditional and allopathic medicine, 10 000 allopathic medical doctors retrained in traditional medicine, 83 000 pharmacists who are specialists in herbal medicines and who have graduated from traditional medicine universities, 72 000 assistant traditional medicine doctors, and 55 000 assistant herbal pharmacists trained in traditional medicine secondary schools (219).
In China, traditional medicines account for 30% to 50% of total consumption (218). There are 800 manufacturers of herbal products, with a total annual output worth US$ 1800 million. There are over 600 manufacturing bases and 13 000 central farms specialized in the production of materials for traditional medicines. There are 340 000 farmers who cultivate medicinal plants. The total planting area for medicinal herbs is 348 000 acres (219).
There are 170 research institutions across the country with perhaps the most prestigious being the Academy of Traditional Medicine in Beijing.
In China, the integration of traditional medicine into the national health care system and the integrated training of health practitioners are both officially promoted (219). The Government of China has reinforced its commitment to the integration of traditional and allopathic medicine on a number of occasions. Adopted in 1982, Article 21 of the Constitution of the People's Republic of China promotes both allopathic and traditional Chinese medicine. The Bureau of Traditional Medicine was set up as part of the Central Health Administration in 1984. In 1986, the State Administration of Traditional Chinese Medicine was established (4). In 1988, the Central Secretariat of the Chinese Communist Party stated the following (220):
Traditional Chinese medicine and Western medicine should be given equal importance. On the one hand, our unique successes in public health and hygiene can be attributed to traditional Chinese medicine. Hence, traditional medicine should not be abandoned. Instead, it is to be well preserved and developed further. On the other hand, traditional Chinese medicine must make full active use of advanced science and technology to ensure its further development. The policy of integration of traditional Chinese medicine and Western medicine should persist. Both systems should cooperate with each other, learning from each other's merit to make up their own shortcomings. Both should strive for the full play of their own predominance.
Again in 1997, the Government reiterated that one of its guiding principles in the field of health care is equality in policies related to traditional and allopathic medicine. The integrated nature of the Chinese medical system is underscored by the fact that traditional and allopathic medicine are practised alongside each other at every level of the health care system (221):
Western-style and traditional Chinese doctors work together at the [township] centre according to the policy of integrating the two systems of medicine. Patients may see either type of doctor.
The 1985 Management Stipulations for Physicians and Assistants of Traditional Chinese Medicine requires traditional medicine practitioners to learn and make use of innovations in allopathic medical technology (213).
The criteria for qualification as a traditional Chinese medical physician or assistant are also set out in the Management Stipulations (222). Qualification as a traditional medical physician can be achieved through a number of routes, typically combining post-secondary academic studies and one to two years of practising, teaching, or researching traditional medicine. By Article 5 of the Stipulations, the academic component can be undertaken at a university or college devoted to traditional medicine, within a department of traditional medicine at a school of allopathic medicine, or by completion of a State-approved diploma or certificate. Under Article 7, a similar, but less demanding, combination of academic studies and one year of practical involvement in traditional medicine is typically needed for qualification as a traditional medicine assistant.
Under a 1985 circular (223) issued by the Chinese Ministry of Public Health's Department of Traditional Chinese Medicine, persons who studied under the former apprenticeship system - in place before the 1960s when formal examinations were not required - may take the formal examinations leading to qualification as a traditional medical physician or assistant. The examinations follow the completion of courses administered by private institutions with Government recognition. The courses may be taken as correspondence courses, night classes, or at workers' universities. Candidates who fail these tests, or persons who decide not to take them, must pass a unified examination offered by the Health Department before their qualifications to practise as traditional Chinese medicine assistants or physicians will be recognized. For assistants, the examination is based on information taught at the secondary school level. There is a more demanding unified exam based on a three-year post-secondary education for those in the apprenticeship system who wish to convert their existing status to the level of pharmacist or physician of traditional medicine.
In addition to physicians and assistants, a third tier of health professional exists in traditional Chinese medicine: individuals examined and officially recognized as proficient in a particular branch of traditional medicine. However, the absence of a uniform method of assessment for these practitioners has led to some unqualified individuals being able to obtain official recognition, according to a 1989 circular issued by the State Administration of Traditional Chinese Medicine (224). Motivated by a desire to protect the integrity of traditional medicine and to safeguard patients' interests, the response of the State Administration has been to introduce annual testing of practitioners in this third tier. Tests are administered by a group of senior traditional medicine practitioners. The annual testing involves both a theoretical component and a clinical examination. Successful completion of the annual testing leads to a certificate, which details the candidate's specific skills and the range of diseases that can be treated. Failing the annual test results in cancellation of the candidate's certificate and right to practise, pending re-examination.
Released in 1988, a series of Provisional Management Stipulations (225) regulates private health care offered by traditional Chinese medical physicians within the State-sponsored socialist health-care system. Article 4 of the Stipulations endorses an official policy favouring preventive care and instructs private-sector physicians to undertake primary health care as designated by the local health authority. The right to practise traditional Chinese medicine privately is restricted to those who have passed the unified examination and technical assessment or who have met the Ministry of Public Health's requirements for regulation as a health professional and have practised medicine in State-owned or collective medical institutions for three years. A licence must be obtained to open a private practice and the licence holder "shall strictly observe the approved practice, place, range of service and business limits to the practice".
Under 1989 regulations (226), traditional Chinese medical assistants are only permitted to open their own practice in rural towns, which include county-level townships and villages. In small towns and cities, they may only serve in private physicians' clinics. Under Article 2, persons with a certified proficiency in a particular branch of traditional Chinese medicine, subject to annual retesting, are only permitted to open a practice at the local county or district level.
Prompted by a desire to protect patients from abuse and deception, regulations concerning medical qigong were enacted in China in 1989 (227). Qigong is described in the preamble to the regulations as "a self-cultivation approach to keep fit through dredging meridians, adjusting the mind, and balancing yin, yang, qi, and blood to get rid of diseases". The regulations provide that practitioners of qigong must obtain approval from the local health authority to teach qigong in public places. By Article 1, teaching must be based on scientific approaches. Under Article 2, qigong practitioners working in medical institutions must possess medical qigong skills and be qualified as traditional Chinese medical physicians or assistants under the Management Stipulations described above. According to Article 4, those who intend to treat patients with emitted qi (energy) must have their methodology and the claimed curative effect approved by the city health authority. If the curative effect is shown to be tenable, based on a study of 30 cases of the same type of illness by a designated medical institution, a licence will be issued. Article 6 prohibits non-medical institutions, including the army, from rendering medical treatment.
Education and training
Traditional Chinese medicine used to be taught through apprenticeships (217). Now, there are 57 secondary schools teaching traditional Chinese medicine, with an enrolment of 29 000 students. These schools train medical personnel for rural and basic units. There are also 28 universities and colleges of Chinese traditional medicine and pharmacology, with a total enrolment of 46 000 students, including 2800 undergraduates. Together, these universities and colleges provide 14 professional undergraduate programmes along with programmes for Master's and Doctorate degrees (4). A chiropractic college is presently being established (81).
To qualify as a physician of traditional Chinese medicine, a candidate must typically complete five years of study. Admissions standards to colleges or universities generally require completion of middle school (seven grades), but there is some flexibility: in some colleges, a primary school education (four grades) is sufficient (191).
As mentioned above, medical education is integrated in China (228). Although there are more allopathic medical schools in China than traditional medical schools, every allopathic medical school contains a department of traditional medicine and every traditional medical school contains a department of allopathic medicine. Between 10% and 20% of the teaching in allopathic medical schools is allocated to traditional medicine (229). A somewhat greater emphasis is placed on allopathic medicine in colleges of traditional medicine. The Division of Traditional Medicine in the Ministry of Public Health suggests orienting 30% of teaching in these schools to allopathic medicine.
Health insurance covers both allopathic and traditional medicine (218).